S 1496 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECFRICAL In 'NO. 1496
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL ESH
.BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: S^ -�^ SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
CtR:S NAMP.: 11i0�_ �� O CONTRACTOR'S NAME: LIC NO:
0 OA N/C CONTROL#
ARCIF IPC'I'/FNGINFEW LIC NO: ADDRESX ❑
CONTACT: PHONEILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) nwG ELECT' PLUMB IGT I
ACHNSFID CONTRACTOR'S DHCI.AI(ATION Q'�. ELECTRIC PERMIT PEE
wmFhy affirm than hap enxee I P n,of m
Chapter 9 aoTt dng ,TOB DESCRIPTION
ApCZ) with Secfon 700(voi'Dwisivin 3 fthe andP fexsons Gvle,aul nylcense is PERMIT ISSUANCE RESIDENTIAL,
CW. in fall force and pfmal ❑SPDWL ❑KITCHEN REMODEL.
az�ju License Class Lic.# APPLIANCES-RESIDEN IAL DITION El PLUMBING RE-PIPE
rF/t¢G Unto Contractor
ARCHITECT'S DECLARATION ❑ ULTI-UNIT ❑STRUCTURAL.
z c o,z- I undCrs[und my plain shall be used as public crook PANELS MODIFICATION
pQ UP T0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
"'W Llccnvnl Pmfnsianal 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEL/REPAIR F1 DEMOLITION
k�C U I hereby (Sam Ibal l nm exempt from the Canons Ca License law for the
%OLD followingmeson.(Section]11315,Business and improve,
deradi h,tar Any city or eonnrY SIGNS ELEGI'RIGAL El OTHER
d3C)y which it,le,sapermit e,okonsde,l1ct.alter,fmpmne,demolish,nrearthanysoudure
�Q thitherslicesemarmarequir theapp...of fm Contractor mFlensignedemtemenl SPECIAL CIRCUIT/MISC.
f pr r]
maintaining
licensed dP a tt hetP oftheContractors t 1 (Chode)or
W 00 (ca g 'I Sat ]Iliad of Di 3 of the BusinessdProfessions Code)or TEMP,METER OR POLE INET COMMERCIAL'
d c a that I pl Ih ref a J theanti, In.alleged d PI Ary -violation of ❑NEW BLDG/ADDI(T'glOryp lfr..MOLI'PION
ti N Soca ]Ili 1.5 by any applicant for a perm I vuh/uLv the appl t 'I penalty f POWER DEVICES El TENANT r 4 CIA, $GRV CE
enot cam Than five hundred dallatrs($SW).
❑Las owneroflhe property,or my employees with wages as their pole emnpewation, SWIMMING POOL ELECTRIC IMPROVEMENT_.
E.aC wdtn
ldonowak, it theatecre isnot intendrdmoffecal fmmde(Seo.91144,IIusumss ❑OTHER
3 ce and Professions Cole:The Cnnvamnr_p License Law does net apply to an owner of OUTLETS-SWITCHES-FIXTURES #
properly who hold,or Impnrves thereon,and who does such work himself nr Ihnmgh
his own employers,provided that such improvements are not Intended or offaed for NEW RESIDENTIAL ELPA SQ t'r.
vale lLhnwevo.the huilJingnrlmpmvement ivxnlA wiNinone yearofmmpletinn.the 2�
SQ.PpaRltfiO� L1dUf Chl /SQ.Pf.
n d
er-buildcr will have the burden of proving that he did nm build or improve bar pur- �„
esalcJ.
p
v owner of Ire property,am rxdusfvcly mnvmOng with licensed ainuvclrrs to T fes"
n 'ct thrpmjmt(Sm.VIWQ Business and Professions Code:)[he Contractor's L,
Ise Law does not apply to an owner ofpropeny who builds or improves thereon,and QTY. 'PLUMBING PERMIT. FEE
who contracts forsuch projects with a contractor(s)licensed pnmuanl In the Contractor
LmcroPERMITISSUANCE
(] tundcr Sec. ,B&PCfnl-s reason
ALTFR-BRAIN&VF,NT-WA' VALUATION
awmr Date _
WORKER' COM ENSATION LARATION BACK PLOW PROI LC IL DC
1 hereby option under penally nl penury one n the following dmleraliocs: C..
❑ Ihxve:mdwillmainwina Cenifiaueof Consenlloself-insurefor Worker's Crnnpen DRAINS-FLOOR,ROOF,A F ,C 1. STORIES TYPE CONSTRUCTION
safmn,as provided for by Section 3900 of dee Labor Code,for the performance of the
work for whieb this parmit is issued. FIXTURES-PFR'1'RAP
El I have and will maintain Worker's Compcasxtion Insumam,as required by Section
3]Wofthe Lima,Coda.ror the parfimman suf the work tin,which this permit is Issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCGGROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Carncr.. Policy No.: GAS-EA.SYSTEM-OV FR 4(EA)
CERTIFICATE OF EXEMPTION I7ROM WORKERS'
COMPENSATION INSURANCE. GREASE/INDUSTRL WASTE INTERCEPTOR
(This_sedion need sol bewmplwwlif the permit is fnrnnc hundrul Julbtm HU NIVISION UFELS l$IOU) GREASE TRAP
nr leve] PLANCHECKF
Trendy that in the performanceafraidt becomewubjectch to parthe Wokers't is Comfort-
SEWP,R-SANITARY-STORM P.A.2(10 Rf.
not employ,any person in any mmmnw m up m become sublet to the Workers'Connpen- ENERGY FEF.
z 'z cation L.vAm C.okrnan Data WATER HIA'IERWNEN'DELECTR
Q Applicant i GRADING PEE
h NOTICE.TO APPLICANT:IL after making dr,C,mramieor Exemption,yen shoo to WATER SYSTEMITREATING
I'• �^ hmrme subject to it,,Worker's Componsntian pmvipinnp ofthe],chair Code,yea must SOILS PEE
Aforthwith comply with such provisions or this permit shall be deemed marked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDId'"I'IAl,PLMII. SQ.PI'. PAID
U C) Ihereby of for that there is a construction lending agency for the performance of are Rec4ipl#
W N the work for which this permit is issued(Sec.3097,Civ.C.)
O U Leader's Name TOTAL:
{>a Lenders Address '(
a 1 party that I have mad this ap,laction and state that the above obstruction its - BUILDIN PTX. ..'s
vl .,,,.an I agree larompl,,ib.l1 city. d ly 1 . Tat 1 ba gats QTY. MECHANICAL PERMIT FEE
U z SEISMIC :;H
above-mentioned property ror impeclinn peepom, PERMIT ISSUANCE
(We) gamr)save,indemnify and keep ham less the City of Cupertino against F.I.HC'I'RIC PEE
liahiallies,judgmcnlv,c...sand esparns which may In any way acerae against said City ALT ER OR ADD TO MECH.
umtmnl thegranting,I thin eIit. PLUMBING PEP. nix
PLIC
NDERS'I'ANDS A WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I goN)CPM) MECHANICAL FEE
SO RCER 'ULATIONS.
AIR HANDLING UNIT(OVER 10.001 CFM)
�/ CONSTRUCTION TAX
Sig of AppliaHAZA DOU Ule EXHAUS'FHOOD(W/DUCI){gZgR (NS MATERIALS UIS LOS RG HOUSING MII'ICA'1'ION FEE
Will the applicant or rubumbuilding occup:mt star candid hamtdous ntalndnl HEATING UNIT CIO 101,11011 B'FU)
as defined by the Cupemino Municipal Code,Chapter 912,and the Health and Safety
Code,Smllor 25532(x)^. HEATING.UNIT(OVER 100,000 BTU)
❑Yes ❑Na
VEN'HLA'fION PAN(SINGLE Ri391 D) PAID _
Will do,applcator future ,ng , ieml
Dale Receipt#
mil terrorist,sr contaminants as dcr,,ed m the Biy Area Air Qually Management BOILER-COMPgQIPOR 100,000BTp
TOTAL
DtpVicf!
❑Yes No BOILERINL
-CGMp(GVERINNIHTU)
I have rad the huarsimismmenal.rouimmemvunder Chapter 6.95of the Cali- AIR CONDITIONER
I p ISSUANCE.DA'PF.
lotion Health&Satiety Codetly ha Sections 25haI i 25533 eandsp 25534.1 understand We If the NEW RESIDP,NTIAI.MECH. SQ.FI.
building does not s ullicy ruse a leoanl,for itis ur responsibility to notify themncy.
of the ttiluimmmis wldJh must he met prior to issuvnm ofa Certificate of Occupancy.
Owner or authorized agent Date ISSUED BY:
OFFICE